Michigan State University Name PID Date I am an applicant for

Name: ______________________________________ PID: ____________________________
Date: ___________________________
_____ I am an applicant for admission to the teacher preparation program.
_____ I am disclosing a conviction and requesting permission to continue in the teacher preparation program.
_____ I am an applicant for internship (Graduate Certification or “GC”) status.
_____ I am an applicant for certification.
Michigan State University
Conviction Disclosure Form
The Michigan State Board of Education has authority under Part 10 Administrative Hearings of the
Teacher Certification Code to deny, suspend or revoke a teaching certificate (R 390.1201).
Students and certification candidates are asked to provide responses to critical questions prior to (1)
admission to the teacher preparation program; (2) internship placement and/or (3) recommendation for
initial certification, renewal of provisional certification, and professional certification. An applicant who
has been convicted of a felony or misdemeanor may be denied admission, field placement, or
recommendation for certification. An applicant who has been convicted of a felony or misdemeanor at
any point during his or her academic program may, upon request, be granted a hearing prior to a final
decision regarding admission, field placement, or recommendation for certification. Such a hearing will
be initiated by the College of Education and referred to the Hearing Board of the Undergraduate
Education Policy Committee for review and recommendation.
Please answer each question by checking “Yes” or “No”. If you answer “Yes” to any question, please
provide complete information on next page.
A. Have you ever been convicted of (or pleaded no contest to) a misdemeanor or felony?
___ Yes ___ No
If you answered yes to this question, you must provide a Register of Actions or Judgment of
Sentence for the conviction from the court in which you were convicted.
B. Have you had a teaching, school counselor, school psychologist, or school administrator
certificate suspended or revoked? ___ Yes ___ No
C. Is there currently action pending against your teaching, school counselor, school psychologist, or
school administrator certificate? ___ Yes ___ No
D. Have you ever surrendered a teaching, school counselor, school psychologist, or school
administrator certificate? ___ Yes ___ No
If you answered yes to question A, please answer the following questions for each conviction. (Attach a
separate page, if necessary.)
a) What was the offense?________________________________________________________________
Fully explain the circumstances. (Attach an additional page, if necessary.)
_________________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
b) What was the date of your conviction? _______________________
c) In what city, state, and country did this occur? __________________________________________
d) In what court? ______________________________________________________________________
e) Please provide any other facts that you consider relevant to this circumstance:
________________________________________________________________________________
_______________________________________________________________________________
______________________________________________________________________________
If you answered yes to any other question, please note the item to which you are responding and fully
describe the nature of the issue. (Attach an additional sheet, if necessary.)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
RELEASE:
I declare and affirm, under penalty of committing fraud in the application process, that all the
statements made in the foregoing application, including its accompanying statement or form, are true,
complete and correct. I further declare and affirm that any conviction that occurs subsequent to the
date of this application but prior to the issuance of any certificate will be reported, in writing, to the
Certification Officer, 134 Erickson, Michigan State University, East Lansing, MI 48824.
By signing this form, I consent to the release of information to Michigan State University for the purpose
of ascertaining my moral character and to the State of Michigan, Office of Professional Personnel
Services, as necessary.
DATE _______________________
STUDENT #: _______________________
SIGNATURE _____________________________________________________________________
NAME (Print) ___________________________________________________________________
ADDRESS ___________________________________________________________________
___________________________________________________________________
E-MAIL ____________________________________________________________________
TELEPHONE ____________________________________________________________________
9/3/2011